Thông tin tài liệu
Laetitia Rispel, Boitumelo Molomo & Sellinah Dumela
South African
case study
on social exclusion
Free download from www.hsrcpress.ac.za
This work was made possible through funding provided by the World Health
Organization (WHO) via Lancaster University. It was undertaken as work for the SEKN
established as part of the WHO Commission on the Social Determinants of Health
(CSDH). The views presented in this report are those of the authors and do not
necessarily represent the decisions, policy or views of WHO or CSDH Commissioners.
Published by HSRC Press
Private Bag X9182, Cape Town, 8000, South Africa
www.hsrcpress.ac.za
First published 2008
ISBN 978-0-7969-2231-1
© 2008 Human Sciences Research Council
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List of tables, figures and boxes iv
Acknowledgements v
Acronyms and abbreviations vi
Executive summary vii
Chapter 1 The global and national context 1
Global response to health inequities 1
South African case study 2
Country profile 2
The current context 6
Chapter 2 Aims and methodology 15
Aims and focus 15
Methodology 16
Chapter 3 Social exclusion:
constructs and policies 19
Constructs of social exclusion 19
Affected groups 22
The impact of social exclusion 23
Social inclusion policies 25
Chapter 4 Appraising South African policies 29
Free healthcare 29
Cash transfers and support grants 31
Bana Pele 33
Summary 38
Chapter 5 Key issues and recommendations 41
Key issues 41
Recommendations 41
References 43
CONTENTS
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iv
Tables
Table 1.1: Health inequalities in South Africa by race (1994) 5
Table 1.2: Selected indicators for South Africa from HDR (2006) 9
Table 1.3: Selected maternal and child health indicators for South Africa (1998) 12
Table 1.4: The ten leading underlying causes of death (2004) 12
Table 1.5: Rank comparison of the five leading causes of death by race (2004) 13
Table 2.1: Key informant interview topics 16
Table 3.1: Health inequities in South Africa (1998) 22
Table 3.2: Categories of policies addressing social exclusion or its proxies 26
Table 4.1: Types of CSGs and eligibility criteria 32
Table 4.2: Bana Pele principles 35
Table 4.3: Summary of policies appraised 38
Table 4.4: Enabling factors for policy implementation 38
Figures
Figure 1.1: South Africa and its provinces 3
Figure 1.2: South Africa’s population pyramid – percentage of the total South African
population in each five-year age group by sex (October 2001) 3
Figure 1.3: Official unemployment rate among those aged 15–65 years by province
(October 1996 and October 2001) 8
Figure 1.4: Burden of disease by province (2005) 10
Figure 1.5: The HIV epidemic among South African antenatal clinic attendees
(1990–2002) 10
Figure 1.6: HIV prevalence by age and sex, HSRC household survey of HIV (2005) 11
Figure 4.1: Bana Pele identification and referral form 36
Boxes
Box 1.1: The legacy of apartheid health services 4
Box 1.2: Summary of the National Household Survey of Health Inequalities
in South Africa (1995) 5
Box 1.3: Trends for social determinants of health (1996–2001) 7
Box 3.1: Constructs of social exlusion 19
LIST OF TABLES, FIGURES AND BOXES
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v
This case study was funded by the World Health Organization (WHO) via Lancaster
University
. Nico Jacobs is thanked for his excellent administrative and logistical support.
We wish to acknowledge the support of Professor Jennie Popay, the overall Social
Exclusion Knowledge Network (SEKN) coordinator.
We also want to thank Karl Peltzer for his input and comments on drafts of the report.
We have greatly benefited from the input and contributions of the 22 key informants,
and other network members. Marijke van Vuuren is thanked for editorial assistance.
We are grateful to the South African Human Sciences Research Council (HSRC) for giving
home to the sub-regional hub.
Lastly, we thank Mary Ralphs and her production team at the HSRC Press.
ACKNOWLEDGEMENTS
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vi
AIDS Acquired Immune Deficiency Syndrome
ANC African National Congress
CASE
Community Agency for Social Enquiry
CBO community-based organisation
CCT conditional cash transfer
CSDH Commission on Social Determinants of Health
CSG child support grant
DoH Department of Health
DSD Department of Social Development
GDP gross domestic product
GPG Gauteng Provincial Government (South Africa)
HDI Human Development Index
HDR Human Development Report
HIV Human Immuno-deficiency Virus
HSRC Human Sciences Research Council (South Africa)
IMR infant mortality rate
IRIF Inter-Regional Inequality Facility
KN knowledge network
MDG Millennium Development Goal
PIMD provincial indices of multiple deprivation
PMTCT prevention of mother-to-child transmission of HIV
RDP Reconstruction and Development Programme
RSA Republic of South Africa
SASSA South African Social Security Agency
SD social determinants
SDH social determinants of health
SEKN Social Exclusion Knowledge Network
SSA sub-Saharan Africa
StatsSA Statistics South Africa
TB Tuberculosis
UNDP United Nations Development Programme
WHO World Health Organization
ACRONYMS AND ABBREVIATIONS
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vii
The World Health Organization (WHO) has established a Commission on Social
Determinants of Health (CSDH) to suppor
t countries and global health partners in
addressing the social factors leading to ill health and health inequities. The most important
objective of the Commission is to leverage policy change by turning existing social
determinants of health (SDH) public health knowledge into actionable global and national
agendas. The Social Exclusion Knowledge Network (SEKN) was established as part of the
work of the Commission. The scope of the SEKN is to focus on and examine the relational
processes excluding groups of people in particular contexts from engaging fully in
community and social life.
South African case study
The aims of the South African case study were to:
Explore the various constructs of social exclusion and its impact on health and •
well-being;
Examine the relational processes that serve to exclude groups of people in particular •
contexts from engaging fully in community and social life, at both macro and micro
levels;
Identify and appraise examples of policies, programmes, actions and institutional •
arrangements that have the potential to address exclusionary processes and ultimately
reduce the impact of health inequalities; and
Explore factors that enable and/or constrain the implementation and scaling up of •
policies and actions to address social exclusion.
This South African case study is based primarily on a review of published literature and
key informant interviews. The document is not intended to provide a comprehensive
overview or scientific analysis of social exclusion experiences or activities. Rather, its aim
is to draw on available knowledge and experience, to highlight lessons learned, and to
contribute to the development of key recommendations of the SEKN.
Chapter 1 gives a high-level overview of the Republic of South Africa (RSA), describes
key aspects of the current policy landscape relevant to promoting health equity, and
summarises available baseline indicators of the scale of inequality. In 2006 the RSA, had
an estimated mid-year population of 47.4 million, of which 51 per cent were female. Life
expectancy at birth was estimated at approximately 49 years for males and 53 years for
females. The 2006 Human Development Report (UNDP 2006) ranks the RSA at 121 out of
177 countries. The overall Human Development Index (HDI) decreased from 0.691 in 2000
to 0.653 in 2004, mainly due to the HIV and AIDS epidemic. South Africa has a quadruple
burden of diseases, consisting of HIV and AIDS, poverty-related diseases, chronic lifestyle
diseases, and high injury rates. The country’s legacy of apartheid is also reflected in
racially-based health status inequalities, many of which persist more than a decade after
democracy. The black African majority continue to bear the greatest burden of ill-health in
the country. Health inequities are also influenced by levels of wealth, geography, and the
educational level achieved by mothers. Access to health services is lowest for those in the
poorest 20 per cent of the population, with 51 per cent immunisation coverage of children
in the poorest 20 per cent, compared with 70 per cent for those in the richest 20 per cent.
Similarly, infants and children under five in the poorest 20 per cent are more likely to die,
compared with those in the richest 20 per cent.
Chapter 2 summarises the conceptual approach to and methods used in the case study,
including limitations. In addition to the literature review, 22 key informants in South Africa
EXECUTIVE SUMMARY
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South African case study on social exclusion
viii
were interviewed, representing senior officials in national ministries, academics and
members of civil society.
A semi-structured interview schedule consisting of 30 questions
was used to collect information from key informants. The project was constrained by time
limitations and numerous competing priorities.
Although a small group was interviewed and no generalisations can be made, the views
expressed present rich perspectives on and insights into the various aspects of social
exclusion and inclusion, and the pathways to health inequalities.
Chapter 3 describes the key issues and themes arising from the South African case study,
comments on informants’ perceptions of affected groups, and the impact of social exclusion
on health and well-being, and concludes with the identification of policies and programmes
with the potential to reduce social exclusion and reduce health inequalities. The social
exclusion discourse has been more extensive in the north and alternative discourses of
poverty, marginalisation and vulnerability have received much more attention in South
Africa. The key informants’ constructs of social exclusion include four main categories,
although these tend to overlap in practice. The contextual construct includes proxy terms
and/or alternative discourses of poverty, marginalisation and disadvantage. The relational
perspective includes political and social systems and processes, and emphasises the multi-
dimensional nature of social exclusion. Extreme marginalisation focuses on categories
of excluded people. The paradox of exclusion/inclusion incorporates the notion of the
adverse incorporation of certain groups of people. The pathways between social exclusion
and health are complex, but four main mechanisms are useful in explaining some of
the complexity. The pathways are social stratification, differential exposure, differential
susceptibility and differential consequences.
Chapter 4 presents an appraisal of three of the policies or actions identified as part
of the South Africa case study: free healthcare policy; social transfers, with a particular
emphasis on the child support grant, and the Bana Pele (‘children first’) Programme,
a Gauteng provincial programme for integrated child care. The free healthcare policy
has been effective in removing barriers to access. Positive effects include an increased
utilisation of primary healthcare services, and an increased use of preventive services
such as antenatal care and family planning. The policy has not had an impact on health
status, but that was not its primary intention. However, there have been unintended
consequences, the most important of which has been negative health-worker attitudes
because of inadequate communication and their lack of involvement in policy design
and discussions on implementation.
With regard to the child support grant, the number of beneficiaries has been rising rapidly,
reaching in excess of six million children in South Africa. Studies have shown that social
grants are the most pro-poor item of government expenditure and provide households
with income, and support second-order effects that further reduce poverty. These include
sending young children to school, providing better nutrition for children, and looking
for work more intensively. The grants have been plagued by implementation difficulties
including fraud, delays in approving grant applications, and difficulties in accessing
payment, with great inequities across provinces. Relatively little is known about the
link between government social grants and the private social safety net, or about the
differential impacts of social grants, by gender and by geographical areas, or their effects
on health or labour migration. It has been argued that the use of a means test and
different interpretations of means testing may act as a significant barrier to the greater
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ix
take-up of social grants among poor households, particularly in rural areas, where the
poor hav
e the least access to the official identification documents necessary to access
social grants.
A rapid appraisal of the provincial Bana Pele Programme shows that many of the services
are not new in the current South Africa social assistance system. The Bana Pele Programme
is implemented through an integrated approach, by identifying, referring and tracking
beneficiaries, and through the establishment of a common database of children in need
within the province. While Bana Pele shows promise and appears to be a worthwhile
endeavour, a formal impact assessment of the programme has not been done. Many of the
current indicators are output-focused (number of beneficiaries) rather than impact-focused
(reduction in vulnerability).
Factors enabling policy implementation include research evidence; political support;
community or civil society support, advocacy and lobbying; public consultation and
debate about policy and programmes; as well as the ability to enforce policy through
legislation, a functioning accountability system, economic growth and cultural support.
The main barriers identified to policy implementation were wide-ranging, and include
political and fiscal constraints, a lack of skills and human resources, the attitudes of public
servants, vested interests of the private sector, misuse or default by consumers, and
inadequate policy communication strategies.
The conclusion highlights that many of the policies in post-apartheid South Africa have
been directed at correcting historical injustices and redressing the wrongs of the past.
However, after more than a decade of democracy, many of the historical and intractable
inequalities remain at both macro and micro levels. The rapid review also shows that
greater attention is needed to ensure the effective implementation of these policies.
Recommendations
Measurement of health inequalities
More attention needs to be paid to the measurement of heath inequalities, including the
extent, degree and gradient of these inequalities.
Policy design, and development
A broader country-wide framework is needed to recognise and address health inequalities,
which includes the social context, sustainable development, health-worker attitudes and
decisive action against HIV and AIDS. The New Strategic Plan on HIV and AIDS provides
hope, but the challenge is in its implementation and communication
Implementation
The following steps are required to address health inequalities:
Raising implementers’ consciousness of the steps necessary to address health •
inequalities;
Reviewing and/or evaluating approaches to the training of policy implementers;•
Ensuring the dissemination of information on good practices; and•
Encouraging networking and the sharing of good practices.•
Executive summary
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South African case study on social exclusion
x
Community responses and advocacy
The following is required in terms of community respose and advocacy:
There is a need for greater advocacy and for increased attention to be paid to •
addressing health inequalities at an intra-country and inter-group level;
Communities need to be sensitised and involved with actions to address health •
inequalities and their causes; and
Advocate for public ministries and civil- society (including private sector) cooperation •
and coordination to reduce health inequalities.
Monitoring and evaluation
The overall monitoring and evaluation system requires strengthening, with sufficient
attention paid to funding, human resources, user-friendly systems and implementation
issues. The involvement of implementing agencies is once again critical, as is capacity
building.
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[...]... appropriate concept? Most of the informants emphasised the importance of context in understanding definitions and terms The relational perspective emphasised the multi-dimensional nature of social exclusion and the political and social systems and processes that may lead to exclusion 19 South African case study on social exclusion A selection of views is highlighted below There is disease-based exclusion, class-based... actions and institutional arrangements that have the potential to address exclusionary processes and ultimately reduce health inequalities and their impact; and 1 South African case study on social exclusion • Conduct selected-country case studies to explore factors that enable and/or constrain the implementation and scaling up of policies and actions to address social exclusion or to promote social. .. categories of excluded people • The paradox of exclusion and inclusion and the notion of adverse incorporation In the theme, which we have termed a contextual construct of social exclusion, key informants questioned the ‘importing’ of the notion of social exclusion into South Africa, as illustrated by the quotations below: This concept has been exported to South Africa where the problem is not a small... the conceptual approach to, and the methods used in, the case study, including limitations Chapter 3 describes the key issues and themes arising from the South African case study, comments on informants’ perceptions of affected groups and the impact of social exclusion on health and wellbeing, and concludes with the identification of policies or programmes with the potential to reduce social exclusion. .. potential to reduce social exclusion and ultimately reduce health inequalities Fortuitously, two of the members of the SEKN in SSA also attended a conference on socioeconomic exclusion that was held in Cape Town, South Africa, and useful insights were gleaned from this conference Aims and focus The aims of the South African case study were to: • Explore the various constructs of social exclusion in the country... schedule, consisting of 30 questions, was used to collect information from key informants The questions focused on the areas highlighted in Table 2.1 Table 2.1: Key informant interview topics Category Areas explored Free download from www.hsrcpress.ac.za Constructs of social exclusion and its effects/impact on health/well-being, including views on social exclusion • Views on understanding social exclusion. .. class-based exclusion, the exclusion drawn out of the behaviour of health workers, and the issue of marginalised and displaced people and refugees Quite often there is a pattern of social exclusion of rural and informal settlement areas, and there is social exclusion on the basis of religion Social exclusion is very broad-based in terms of how it manifests There are certain pathways to social exclusion: some... and inclusion and on health inequalities 17 Free download from www.hsrcpress.ac.za CHAPTER 3 Social exclusion: constructs and policies This chapter describes the key issues and themes arising from the South African case study, comments on informants’ perceptions of the most affected groups, the impact of social exclusion on health and well-being, and concludes with the identification of policies and... The concept of social exclusion also includes exclusion from healthcare, water supply, social grants as well as access to education We know that education is one of the most powerful sectors that can impact on women’s health Social exclusion starts working at the village and local community level, at the town and city level, region or province level, the national level, at the level of Africa Beyond... society 25 South African case study on social exclusion Table 3.2: Categories of policies addressing social exclusion or its proxies Category Enabling framework or value system Examples Brief description Reconstruction • Developed by the ANC and alliance partners and through extensive community consultations and Development • An important development strategy, which became the Programme blueprint for social . implementation and scaling up of policies and actions to address social exclusion
or to promote social inclusion.
South African case study
The South African case. African National Congress
CASE
Community Agency for Social Enquiry
CBO community-based organisation
CCT conditional cash transfer
CSDH Commission on Social
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